For Alumni
Stanford
MD

On the Cover

Cover illustration by Calef Brown.

Stanford Medicine, published quarterly by Stanford University Medical Center, aims to keep readers informed about the education, research, clinical care and other goings on at the Medical Center.

Alumni Profile:

get organized, doc

By Mitch Leslie

DOCTORS OF AMERICA,

UNITE!

YOU HAVE NOTHING TO

LOSE BUT YOUR SHACKLES

OF RED TAPE.

For nearly 30 years, ROBERT WEINMANN, MD, has been preaching the gospel of physician solidarity
to anyone who would listen.
Nothing short of a robust union,
willing to strike if necessary,
can shelter doctors and
their patients against the
powerful forces that seek
to control medicine -- from
regulation-happy bureaucrats
to what Weinmann once called the
"greed-encrusted barons of
managed-care exploitation."

"I apologize for the
modesty, the soft-spoken
approach and the
temperate language"

of that remark, he laughs. The combative Weinmann, president of the 6,000-member Union of American Physicians and Dentists (UAPD), is not the apologizing type. An English literature major at Yale, the Stanford medical alum, class of 1962, delights in deploying his rhetorical gifts to pummel and provoke his opponents and to expose the misdeeds of the high and mighty.

These days, the favorite target for his many speeches, op-eds, TV and radio interviews and union press releases is managed care, which he contends has mutated into a larcenous system for enriching stockholders and "ravenous executives" at the expense of patient health. "No more predacious an industry exists in America today than managed care," he began a 1996 op-ed.

Ironically, managed care is partly responsible for galvanizing the labor movement among doctors and for bringing Weinmann and the UAPD a large and influential audience. Politicians at all levels of government have sought his diagnosis of medicine's ills. He appears regularly before the California legislature. A year and a half ago he met with President Clinton at the White House to discuss HMOs and patients' rights, and both Weinmann and the President answered questions at a post-meeting press conference. At the invitation of Reps. Henry Hyde (R-Ill.) and Tom Campbell (R-Calif.), last summer Weinmann testified before the House Judiciary Committee during hearings on a bill that would legalize collective bargaining by doctors in private practice. Current antitrust law gives this right only to the one-third of the nation's physicians who are considered employees, such as those who work for a hospital, a university or an HMO.

Exasperated by the restrictions on their practices and pay imposed by managed care, doctors are seeking strength in numbers. According to the New York Times, about 35,000 of the country's roughly 620,000 doctors now hold union cards -- a small fraction, true, but an increase of 40 percent in just three years. Weinmann's UAPD grew by nearly 20 percent on one day last spring, when the 800 doctors who work for Los Angeles County voted to join. Last fall, residents and interns won the right to organize. And even the conservative American Medical Association, responding to seething discontent among its 290,000 members, voted last summer to form a bargaining organization that would help doctors negotiate contracts -- what Weinmann calls a "quasi-union" because it vowed never to strike.

Weinmann forecasts an even bigger future for the union movement. Once doctors see the benefits of organizing, he says, they will rush to join -- if they can set aside their own snobbery. The attitude of his peers is the biggest obstacle to union growth, Weinmann says. "We encounter yesterday's snobbism all the time, especially from people whose thinking is obsolete." His message to doctors who look down their noses at unions is characteristically candid: We don't need you.

Weinmann's upbringing instilled a much different view of unions and political activism, he says. He grew up in Newark, N. J., in a house where medicine and public service were constant topics of conversation. His uncle was a doctor and his father was a dentist and activist in the campaign to establish the state of Israel after World War II. As Weinmann helped out, he learned valuable lessons about distributing political information and met influential people on both sides of the debate -- including future Israeli Prime Minister Menachem Begin and several Egyptian officials.

After high school, WEINMANN TOOK A SUMMER JOB IN A FIRE EXTINGUISHER FACTORY THAT TURNED OUT TO BE AN EYE-OPENER. ON THE FIRST DAY, THE SHOP STEWARD CAME UP AND ASKED FOR UNION DUES. When Weinmann protested, arguing that he would only be working there a few weeks before going away to college, the steward replied by pointing out what the union had accomplished for the employees. They had a clean, safe, well-lighted place to work, Weinmann recalls, all because of union efforts. After a discussion, the union accepted Weinmann's argument and exempted him from dues as long as he went to college. Working in that factory that summer transformed his view of unions.

Weinmann's father warned that he might regret not joining the union. About 20 years later, he got another chance and took it, becoming a member of the small, year-old doctors' union in 1973. With a couple of hundred members scattered around California, the infant union was more of an advocacy group, focused on the looming threat of further government intrusion into medicine. Weinmann served as a co-chairman of the union's grievance committee and vice president and president of the local while establishing his reputation as a gadfly through his stinging commentary in the Night Letter of American Medicine and the Santa Clara County Medical Bulletin -- both of which he edited.

In the muckraking Night Letter, he blasted anyone he thought was intruding on the doctor's turf, including the governor and state legislature, bureaucrats at every level of government and lawyers. Especially lawyers. He once described them as "grand inquisitors with license to maim and destroy" and wrote that "disreputable practice in law, in our courts, will only cease when the public takes as much interest in the legal profession as the legal profession has always taken in everybody else's business."

In 1977, Weinmann also dropped a bomb on his alma mater, charging that the compensation regime at Stanford hospital, which allowed doctors on the payroll to charge patients for professional services, amounted to double billing. What's more, he asserted, staff doctors were charging for procedures actually performed by interns and residents. An investigation proved Weinmann right: Stanford eventually had to repay $1.5 million to Medicare and another $300,000 to the State of California. And other academic hospitals, including Harvard and the University of Pennsylvania, were caught doing the same thing.

With their eyes warily on the political left, doctors were unprepared for what happened with the arrival of managed care. "Doctors didn't expect to get slammed by the right wing -- they were the right wing," Weinmann says. In the beginning, Weinmann concedes, HMOs did restrain soaring medical costs by eliminating unnecessary tests and procedures. But once HMOs had trimmed the excess, he says, they had to continue slashing in order to keep profits growing.

In Weinmann's view, an insidious system has evolved that shortchanges both patients and doctors. Because patient care is considered an expense that eats into profits, HMOs make money by saying no to tests and procedures, he says. Constantly second-guessed by accountants, doctors are left feeling powerless and beleaguered, uncertain that they can practice medicine in a way that serves the best interests of their patients.

Weinmann inveighs against the injustices of managed care whenever he can. He fills his writing with lurid tales of HMO abuse: patients denied essential care; patients shuttled from hospital to hospital at the whim of their HMOs; patients left unattended while medical equipment malfunctions because of staff cutbacks.

Why don't doctors fight back? HMOs control how much a doctor earns and whether he or she can even work, deploying an array of subtle tactics to discourage rebellion, Weinmann says. A target of some of his angriest writing is the practice he named "medical red-lining," in which a doctor is judged for retention or admission to a health plan or hospital based on economic credentials, rather than on training, experience or skill. That is, whether a doctor can get or keep a job often depends on how cheaply he or she treats patients. A health plan can simply fire someone whose cost per patient is too high -- not only shedding an expensive doctor but eliminating his or her costly patients as well. The dismissed doctor also becomes an example, a tool for pressuring other doctors to reduce their costs, Weinmann explains. The practice is particularly insidious, he says, because doctors who work in poor communities often have higher costs and are therefore more likely to be fired.

The beneficiaries of this penny-pinching, Weinmann charges, are executives and stockholders of HMOs, who reap lavish salaries and windfall returns on their stock. A case in point, he says, is the CEO of a managed-care company who took a $1 billion buyout -- a sum that included $24 million for a private jet and a $2 million "fuel allowance." "The money for that billion-dollar payout came from thousands and thousands of refused tests and procedures," Weinmann says.

Though the litany of complaints against HMOs has become familiar, Weinmann takes his attacks further than most, arguing that managed care threatens the long-term quality of medicine. He warns that managed care is making medicine so unattractive that medical schools will have a hard time attracting the best and the brightest. "When doctors have to fight to get an MRI done, when doctors have to fight to get an assistant surgeon, an atmosphere is created that destroys the private expectation of excellence."

Doctors cannot defy managed care alone, Weinmann argues. But with union backing and skill, doctors can negotiate contracts that allow them to provide adequate patient care without putting their jobs at risk. And the union can provide more than negotiating expertise, Weinmann points out. The UAPD promises all the power and know-how of an organization "skilled in the art and craft of negotiation and confrontation." A union representative will sit beside you at medical boards or during a Medicare audit. If you are dismissed without cause, union lawyers will take up your case, filing a lawsuit if necessary. If you are a researcher, the union can help you negotiate for more lab space or better equipment.

The UAPD's vision of a full-service union in the old style contrasts with what the AMA proposed last summer. The AMA even shied away from the inflammatory word "union," preferring the euphemistic "affiliated labor organization." And while this organization will form bargaining groups to help negotiate contracts, it will not actively recruit members and vowed never to strike -- in Weinmann's view abandoning its most powerful weapon. Although the UAPD has authorized two strikes in its history, neither actually came off -- the threat was enough to restart bargaining, Weinmann explains.

Relations between the AMA and the UAPD have often been chilly. A 1989 article in the Journal of the American Medical Association questioned the legality of some of the UAPD's bargaining tactics. Shortly afterward, the Federal Trade Commission launched a yearlong investigation of the UAPD -- a probe that ultimately exonerated the union. Weinmann still blames the AMA for siccing the feds on his union, but he also feels vindicated. "It made the AMA look foolish -- not to mention that 10 years later they voted to form a quasi-union of their own."

Despite the bad blood, THE UAPD AND AMA WILL BE FIGHTING ON THE SAME SIDE IN SOME LEGISLATIVE BATTLES. BOTH ORGANIZATIONS ARE PUSHING FOR THE REPEAL OF LAWS THAT PREVENT DOCTORS IN GROUP OR PRIVATE PRACTICE FROM UNIONIZING.

If they are successful, the majority of doctors would be allowed to bargain collectively, a big boost for the union movement. And both groups back the stronger version of the so-called patients' bill of rights, which passed the House of Representatives last summer. The bill would give patients the right to a second opinion, the right to go to the nearest emergency room and the right to sue their insurance companies if they feel their care was inadequate.

This controversial provision was absent from the weaker Senate version of the bill, but Weinmann argues that it's essential. To him, the issue boils down to fairness. If HMOs insist on practicing medicine, he argues, they must be willing to accept economic responsibility for their decisions, just as doctors are required to do. The two chambers will be hashing out a compromise bill this year.

Two years ago the UAPD TOOK A STEP THAT WILL GREATLY INCREASE ITS NEGOTIATING CLOUT. IN 1997, THE UNION BECAME AN AFFILIATE OF THE AMERICAN FEDERATION OF STATE, COUNTY AND MUNICIPAL EMPLOYEES (AFSCME), A 1.3 MILLION MEMBER UNION OF THE AFL-CIO. This was the UAPD's third attempt at joining big labor. The AFL-CIO had rebuffed the UAPD twice previously. This time, though, four different AFL-CIO unions came courting. The UAPD chose the AFSCME because "we were allowed to retain our political autonomy, our independence of activity, and to decide what the medical issues were and to relay them back to Washington," Weinmann says.

Despite the UAPD's growth, Weinmann still sees reluctance among doctors to join a union. Snobbery is a big part of it, he says, but other faulty beliefs also contribute. For instance, medical training instills a can-do attitude that encourages doctors to think they can handle their own finances. They can't, Weinmann says, especially when they're up against HMO sharks. Many doctors can't even read a financial report, Weinmann notes, and it's a snap to draw up a contract that looks attractive on the surface but that contains all sorts of hidden provisos and conditions that make it unfavorable for the doctor.

Other physicians protest that unions are "unprofessional." But Weinmann argues, "Is standing independently and losing one fight after another more professional? There's no reason for collective bargaining if you enjoy losing. The Union of American Physicians and Dentists was formed for doctors who prefer winning."

Others naively believe that hospitals, universities or other employers are looking out for their interests. What they need to realize, Weinmann says, is that "doctors contribute to the expenses of these places."

These days, Weinmann is casting his eye on Stanford again -- not to attack but to attract new members. Academic medical centers are prime targets for recruiting, he says. The union already has some members at Stanford, though he declines to name them. "How they benefit is something we know and they know, but we don't flaunt it." Moreover, the UAPD just unionized 800 doctors in Los Angeles County, including 550 with teaching appointments at UCLA, USC and Charles Drew University. Once the doctors at Stanford see how well these new union members fare, Weinmann predicts, "the Stanford faculty will line up behind their old classmate, and I will buy another Stanford tie." SM